Parents and politicians share the same struggle: How do we make people behave?
The new Ontario government talks about accountability almost as much as it does about debt.
No money means no carrots, which leaves only sticks. Is leadership only carrots and sticks?
Leadership is influence. Influence comes from relationship. Successful leaders influence others toward positive ends. As a parent/leader, how do you make your son clean his room?
You could:
Give a pep talk.
Lay down the law.
Nag.
Bribe.
Give up. He’s a boy.
Change Doctors’ Behaviour
Governments repackage these tactics to change doctors’ behaviour. Politicians often:
Give a pep talk from a famous leader on the privilege of caring.
Tighten accountabilities (Lay down the law).
Increase oversight and add behavioural prompts (Nag).
Incentivize behaviour and offer bonuses (Bribe).
Give up. Impose global cuts and offer sub-inflationary fee increases.
System leaders repackage the same rules for everything: after-hours care requirements, surgical outcomes, in-patient lengths of stay, etc. But better rules do not guarantee better patient care. Better rules make doctors focus on rules, not patients.
Rules change behaviour the way speed limits change driving habits. People perform to the limit of what goes unpunished. This Faustian deal works for speed limits. It does not work for patients.
Rules Without Relationship
This is not an argument for anarchy. We need rules. But rules without relationship create perverse outcomes.
No tactic works all the time for all people. Tactics work only as well as the relationships they leverage. Simply “tightening accountabilities” without addressing relationship will not change behaviour.
Without relationship, nothing changes.
Relationship does no mean warm hugs and wooly hunches. In leadership, relationship requires a precise and acute understanding of the people you want to influence.
Parents change behaviour by understanding their children and applying the right tactic. It works the same for doctors.
Government cannot demand change without understanding what doctors do and think. I expand on this in Impossible to Manage Doctors?
Accountability Without Freedom
You cannot change doctors’ behaviour without discussing freedom to change. I wrestled with this in one of my first blog posts and more recently here.
The Ministry of Health demands accountability without paying for it. Physicians expect incentives with limited accountability.
We need both. Accountability without payment is slavery. An incentive without accountability is robbery.
We need accountability and meaningful incentives. We should align incentives and reward outcomes that benefit patients.
Accountability presupposes freedom. It is nonsense to increase accountability without reducing red tape at the same time.
Give providers freedom, then demand accountability. It makes no sense to demand accountability without giving providers freedom to deliver results.
Accountability must be inverse to the regulatory burden. If payers micro-manage every system process and detail, they remove freedom from providers and have no right to demand accountability on outcomes.
Adam Smith said that self-interest inflames our desire to do a good job. The Butcher does a great job because he loves your business, not you.
But it is not that simple. Adam Smith did not intend to reduce us all to economic beings (homo economicus).
No one has monochrome motives. We rarely act purely from greed, fear, love, or anger. We usually have a jumble of passions.
Compassion mixed with professionalism and self-interest and etiquette and peer pressure and a dozen other motives produces great patient care.
Reducing care to rules and accountabilities just frustrates doctors and corrupts patient care. It will not change doctors’ behaviour.
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Wisdom well spoken
Thanks!
Accountability cannot exist without defining responsibility. How can one be held accountability without a clear agreement on what one’s responsibilities are? The word is misused too frequently.
Well said, Johny!
We would embrace accountability if it was defined and we had the freedom to deliver. With changes every 4 years and nebulous rules, no one benefits.
Thanks for posting!
“Better rules make doctors focus on rules, not patients”–Shawn Whatley
Thanks Gerry!!
Agreed. Accountability must be balanced with freedom . I expect my 21 year old to be accountable in how he uses my car , what time he comes home and who he hangs out with but in turn he has to have the freedom to decide where he goes , what time and with whom . The MOH wants to micromanage us without input and then expects us to be accountable to their imposed rules .
Well said, Zoey! “The MOH wants to micromanage us without input and then expects us to be accountable to their imposed rules.”
Accountability! A powerful word. Doctors must be accountable in order for the government and the college to oversee the work doctors do. Ah, the ubiquitous word, paperwork. Reams and reams of it. Are our doctors getting paid to be accountable? Family doctors fees are in danger of being cut by 25% and maybe that will make sure the paperwork is done. In a dictatorship, accountability of the professions is absolute and no payment is ever mentioned. A Section 75, will this ensure accountability?
Maybe the college needs to be accountable?
Good point, Paul.
An ear infection used to be charted as: “AOM. Rx: Amox”. Now we need paragraphs about everything that wasn’t found.
The first people who need to be accountable are the legions of Bureaucrats in MOHLTC.
Great point!
Fundamentally the government wants to treat us employees. Yet we think of our selves as professional independent contractors.
We have a system with all of the expectations of an employees with out it benefits and all of the costs of an independent business without its benefits. This mix of approaches is killing physicians. We must negotiate that if governments want to govern us as employees then we must also have the benefits of employee. Work space provided, overtime pay, sick pay vacation pay pension etc. If they want us to be independent contractors then we must be treated as such. As a profession we must look hard at what we want ourselves because they current system does not work for us. May be it is time to give up the concept of independent contractor because clearly the government has.
Well said, indeed.
I really like your lines, “We have a system with all of the expectations of an employees with out it benefits and all of the costs of an independent business without its benefits. This mix of approaches is killing physicians.”
Doctors graduate with debt and stay buried in it for years. A small gap exists in which doctors have paid off debt and have time to pay attention to medical politics before they lose energy and look for the exit. This perpetuates the next crop of debt slaves. No doubt, this happens in other industries too. But no other industry has been nationalized like medicine while keeping alive the popular vision of “private practice”. Private presumes control and autonomy. Every year, most governments work to whittle away the private left in private practice.
Thanks for taking time to read and post a comment!
This is exactly what I mean that one cannot be held accountable without a clear description of responsibilities in an agreement. There are so many different assumptions in our health system, and people are held accountable on these different assumptions. We should start at the start by asking, what is the purpose of the Canadian health system? Last time it was talked about was in the 60’s